They lined up early in the morning, just as the sun was rising. They awaited the team’s arrival outside the small church constructed of irregular, wooden walls and a tin roof, on benches that usually function as church pews. Far off the paved road, on a path of rocks and dirt carved in the grass by foot traffic, they assembled expectantly.
The mobile clinics serve as part of Project Medishare’s primary care outreach to the population that lives too far away from the standard clinics to receive routine health maintenance. Out here, patients typically wait until they are rather ill before hiring a motorcycle taxi to take them to the fixed clinic. The mobile clinic, then, is for the lumps and bumps of life that you and I would seek medical care for, but that remain outside the reach of this impoverished rural community.
For me, the rural clinic was a renewal, a rediscovery of my roots in global health. When I tell people that I work in Haiti, they picture me toiling in a one-room clinic in a rural setting, but truthfully most of my time is now spent in a hospital with an intensive care unit and a chemotherapy infusion center. But as soon as I arrived at the rural clinic, the smell of earth and poverty reminded me why I decided to work abroad — overwhelming medical need for those in intense poverty and a patient population as kind as they are grateful.
Patients came dressed in their Sunday best, complete with combed hair, hats and colorful barrettes. I called out the patients names one by one when it was their turn to join me on the rickety church pew. At first, they didn’t know how to respond to the foreign doctor speaking Creole. One 12-year-old girl grasped my arm hair between her thumb and forefinger as I listened to her heart, tugging at the tufts of thin hair, fascinated by the quantity and texture of the white doctor’s arm hair. Soon, however, the clinic settled into a routine and our differences faded away.
One 10-year-old boy came by himself to the clinic and complained of some abdominal pain and diarrhea. I examined his belly and wrote him a prescription for medications. He walked barefoot to the pharmacy where he was handed two small plastic bags of drugs and given explicit instructions. He then hopped onto a woven straw saddle that sat atop a donkey that was carrying a sack of recently harvested vegetables. He would have appeared tiny on top of a horse, even a malnourished Haitian horse, but the donkey was perfectly sized for the underdeveloped 10-year-old boy. With a click of his heels, he rode off on the donkey, down the rocky path towards his home.
As the day progressed, the sun moved in the sky and the shade offered by the large mango tree shifted as well, leaving me and the patient in the sun. Every fifteen minutes, we’d drag the thin wooden pew towards the center of the tree, hoping to avoid the scorching heat.
The medical problems of the entire community were on display and dozens of patients and their families participated in the medical exams of their friends and family. Patient histories were completed not just by the patient, but by whatever villager was in earshot of my questions. I felt at first that I was violating the patients’ confidentiality, but soon remembered that the cultural norms are different in Haiti, and everyday illness is discussed as a routine matter of conversation. While severe illnesses like AIDS and cancer would stigmatize a patient in this community, parasites and skin infections do not.
I interviewed one older gentleman and asked him if he drank after noticing clinical signs of alcoholism. “_Mwen gout clerin_,” he responded with a grin. I taste moonshine.
A nearby villager retorted, “Either you drink or you don’t. Nobody just tastes clerin.”
“Oui. I drink clerin,” the man admitted with a toothless smile and the crowd giggled along with him.
While performing a neurological exam, he couldn’t understand my instructions to push here and pull there, and his friends reinforced each request of mine by demonstrating what maneuver it was that I wanted him to perform. People in the back row of the waiting area soon began shouting my instructions back at him as well, the old man’s brain slowed by years of tasting clerin. When I asked the patient to push with his leg towards me, one of his friend’s shouted from the back, “Don’t kick the doctor!” The entire outdoor clinic erupted in laughter, including the patient, a shared bond at the end of a long day for the town’s sick.
We diagnosed three patients with cardiac conditions that require further work -up with an ultrasound machine. I asked all of them to come see me the next day at the hospital in Port-au-Prince, a 4-hour journey, but the only place that I can look at their hearts myself and guarantee their follow up. Two said that the trip was too difficult, so I referred them to our partners at the nearest hospital, never knowing if they would get lost in the system. I saw the third patient with a murmur in his heart the next day in the hospital in Port-au-Prince and delivered the bad news that his heart was structurally abnormal, but that there was no further diagnostic testing available in Haiti to determine the exact cause of his problem. Despite being a sophisticated critical-care hospital, there are still many conditions that we do not have the capability to address. I prescribed the 30-year-old man medications to reduce his symptoms and the chance of mortality from the most likely causes of his murmur and chest pain.
I saw the last patient of the day as the sun had started to cast a long shadow from the shade tree, providing a generous area for the staff and remaining patients to seek relief from the heat. She was a young woman of 21 years with honey-colored eyes and a thin 6-month-old baby in her arms. The baby had three different types of skin maladies — scabies, fungus and a bacterial infection on top of the open wounds created by the first two. Fruit flies swarmed around the tiny baby’s open wounds, and the sickly-sweet smell of poverty arose from the mother. The baby was too young for the available treatments for scabies and fungus. I simply advised the young mother to pursue better hygiene for the child and gave her medications to provide symptomatic relief for the little one.
We loaded the remaining medications into the SUVS before the staff climbed in to head home. Down the mountain path sat a cell phone charging station with its power cords hanging off like the tentacles of an octopus and painted in the bright red color of the telecommunications company. When I served in my first rural clinic in Nicaragua in 2002, the trip where I fell in love with global health, I’d never have dreamed of such a sight. Despite the changes, I still feel perfectly at peace in the mountains of Haiti.
Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.